VARIATION IN THE MANAGEMENT OF PEDIATRIC DIABETIC-KETOACIDOSIS BY SPECIALTY TRAINING

Objective: To compare management strategies for pediatric diabetic ket oacidosis (DKA) among physicians with different specialty training. Me thods: We conducted a mail survey of 1000 randomly selected physicians , including 200 pediatric endocrinologists, 200 general emergency phys icians, 200 pediatric emergency physicians, 200 pediatric intensivists , and 200 pediatric chief residents. We posed questions regarding a hy pothetical 10-year-old patient with new onset of diabetes mellitus who is approximately 10% dehydrated but alert, with venous pH of 7.1 and serum glucose concentration of 34.7 mmol/L (625 mg/dL). Questions invo lved the rate of rehydration, content of intravenous fluids, insulin t herapy, potassium replacement, use of sodium bicarbonate, and adjustme nts in therapy for decreasing serum glucose concentration. We compared responses of physicians in each specialty and used multiple regressio n analysis to adjust for potential confounding variables, including nu mber of years in practice, number of children with DKA seen per month, and practice setting. Results: Five hundred eighty-one physicians (58 .1%) completed the survey, with responses demonstrating significant, c onsistent differences between specialties. Extremes of responses inclu ded the following: (1) 59% of endocrinologists vs 11% of general emerg ency physicians would give an initial fluid bolus of less than 20 mL/k g (odds ratio [OR], 11.7; 95% confidence interval [CI], 5.0-27.7) (P<. 001); (2) 83.5% of general emergency physicians vs 42.5% of pediatric intensivists would administer an initial insulin bolus (OR, 4.1; 95% C I, 2.0-8.7) (P<.001); (3) 58.2% of pediatric intensivists vs 9% of gen eral emergency physicians would replace fluids over a period of greate r than 24 hours (OR, 14.1; 95% CI, 5.5-37.5) (P<.001); and (4) 54.3% o f general emergency physicians vs 7.3% of pediatric intensivists would use potassium chloride alone for potassium replacement (OR, 10.8; 95% CI, 5.0-23.8) (P<.001). All of these differences persisted after adju sting for the potential confounding variables. Conclusions: Substantia l differences exist in the management of pediatric DKA among physician s of different specialties, presumably due to differences in specialty training. These differences obscure our ability to evaluate the treat ment of DKA and highlight the necessity for further studies comparing the outcomes of different treatment strategies.